One of the greatest advances in my adult life has been the restriction on smoking in public places. The laws that prohibit smoking in restaurants, jazz clubs, and airplanes have been, for me, a great gift of a civilized society. Thank goodness we do not have a constitutional amendment protecting the right to smoke. The absence of the smell of smoke may have dulled my perception of how destructive this habit has been on cardiovascular health during my lifetime. In a recent conversation with a good friend who is always expecting a heart attack at any minute, I was prompted to ask why he was concerned. He is 70 years of age (a clear risk factor), but has no other identifiable risks except that his father had a myocardial infarction at 38 years of age and a fatal one at 41 years of age. That is clearly enough to get one’s attention. His father was a World War II veteran who was part of that massive misdirection of charitable intent, the provision of free cigarettes in every pack of C-rations given to our young soldiers. They were taught to smoke. “It will make you a man,” they were told. Yes, constant smoking will give you a heart attack in your 40s quite often. I examined the impact of smoking on very premature coronary artery disease when I established the cath lab at Emory Hospital in the early 1970's. Men and women younger than 50 years of age who had arteriographically visible coronary lesions were overwhelmingly smokers. When Andreas Gruentzig began to look for ideal candidates for balloon angioplasty, he found them among young men who smoked. Smoking is frequently associated with severe single-vessel lesions in the young population (ideal targets for balloon angioplasty with the original crude equipment that was available then). I reviewed with Maria Schlumpf, Gruentzig’s assistant, the patients he treated in Zurich before joining us at Emory (1,2). The long-term outcome of these young patients after simple balloon angioplasty was quite good. The first patient, Mr. Dolf Bachman, was well the last time I saw him, now approaching 40 years after his angioplasty. The remarkable results may be less from the balloon than from interruption of the stimulus for endothelial dysfunction and hypercoagulability that produced the “ideal coronary lesion.” Almost all the patients were smoking before percutaneous transluminal coronary angioplasty and most stopped after. Perhaps the charismatic personality of Andreas was powerful enough to cause them to adhere to his order to “halt” smoking. But how do we convince our patients? I have always felt one of the best motivators is fear. I came to that conclusion from personal experience. As a young person growing up in the 1950s, I was addicted to the cigarette packages as much as the nicotine. For summer work in the paper mill, I competed with my coworkers by smoking Camels, for a horseback ride in the country it would be Marlboros (remember the Marlboro man), and for sailing at the beach, Newports were the staple. (Thank goodness this makes no sense to those of you younger than 50 years of age). I was smoking through college and medical school, as were many of my classmates and our faculty. The event that got my attention occurred when I was a medical officer with the 25th Division in Hawaii. Routine chest x-rays were required then, and as I sat reading them one Friday afternoon, I came across one with a 1 cm “coin lesion” in the mid-right lung field. I took my grease pencil and drew a circle around it before looking at the name on the film. It was mine! I left my dispensary and drove to Tripler Hospital, walked into the radiology department and presented my film to the only person there—a first-year resident. He looked at it and said, “This does not look good, but come back Monday and we will show it to the staff radiologist.” The weekend was an anxious one. On Monday I returned. The staff radiologist repeated the poor-quality x-ray I brought him and then pointed out the concentric calcification in the “coin lesion” and the calcification in the hilar nodes. “Where did you grow up?” he asked. “Western North Carolina mountains,” was my reply. “Yep, this is histoplasmosis and you need not worry.” I guess he recommended a follow-up x-ray but the psychotherapy had been applied that weekend. That was my last cigarette. So fear is my personal best method for stopping, but there are others. Now I do not smell smoke but I see vapor. More and more young people are being addicted to smokeless cigarettes. Are these the entry drug to smoking tobacco? What incentives are there to inhibit smoking? Many states have increased the tax on cigarettes to a level that makes it difficult for young people to get started. These measures have been documented to reduce the incidence of smoking. In my state of Georgia, we have one of the lowest cigarette taxes in the country. Attempts by the American Heart Association affiliate to have the taxes increased were previously defeated with the explanation that no new tax would be imposed on people who choose to smoke (long live liberty). But the legislators who were presented with the prospect of increased revenue from such a tax could not resist and promptly imposed a hospital bed tax to replace the potential gains from a cigarette tax. So instead of incentivizing a reduction in smoking, the tax was applied on the very institutions treating the effects of smoking. Now legislation is pending and hopefully good sense may finally prevail.

How many children of the “greatest generation,” such as my anxious friend, had to grow up without fathers because of our societal mistake (free cigarettes for all)? Public health requires that public policy is consistent with what we know so well but have not had the courage to implement.